Some patients may develop hepatic infarction following pancreticoduodenectomy or other major pancreatic operations. Winter et al developed a protocol for monitoring patients after major pancreatic surgery. The authors are from Johns Hopkins University. Thomas Jefferson University, and Indiana University.


A significant elevation in the hepatic transaminases may be seen with:

(1) systemic hypotension

(2) vascular damage, including ligation

(3) thrombosis


Prompt revascularization and restoration of blood flow may be able to prevent hepatic injury following vascular injury, ligation or thrombosis.



(1) serum level of ALT and AST

(2) trend in the serum levels (rising vs stable/declining)

(3) presence of an alternative explanation for the findings


If the postoperative transaminases are elevated, then monitor the transaminases every 6 hours until the levels stabilize.


Perform hepatic duplex scanning of the hepatic artery and portal vein if:

(1) The transaminases are >=500 but < 1,000 IU/L and the levels are rising.

(2) The transaminases are >= 1,000 IU/L.


Consider magnetic resonance angiography, angiography, high resolution CT or exploratory laparotomy if the serum transaminases are >= 2,000 IU/L


To read more or access our algorithms and calculators, please log in or register.